Rotational Atherectomy, Cutting Balloons, Angiosculpt & Lacrosse

y dissection 
• Saphenous vein grafts 
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Philosophy 
• Is it easier to prevent than to treat 
• It is easier to prepare the lesion than struggle later 
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Differential Cutting 
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Elastic Tissue Inelastic Tissue Rotary Sander 
Preparation 
• IABP if unstable, high-risk, low-EF, early-experience 
• TP especially for RCA 
• Standby rescue equipment: pericardiocentesis, covered stents 
• Covered stents: Graftmaster Jostent, Bestent, 
• Guide size 
• Rehearse steps going in and coming out 
• Defibrillator on standby 
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Preparation 
• Get intracoronary vasodilators ready: pretreat before root a 
good idea 
• Verapamil 100mcg, adenosine 100mcg, nitroprusside 10-
20mcg, GTN 100mcg 
• Appropriate anti-platelet therapy 
• pre-loaded with DAPT vs. GP IIB/IIIA 
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Technique 
• Platform speed at 150,000 RPM before inserting into guide 
• Advance through guide into coronary - if resistance, use Dynaglide 
(40,000 RPM) mode 
• Platform speed again at 150,000 RPM before ablating plaque 
• Advance rotating burr to contact plaque for 5 -10 seconds (without 
slowing burr more than 5,000 RPM drop) and then pull burr back 
proximal to beginning of lesion 
• Repeat this procedure until you have crossed the lesion 
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Microparticles 
• Smaller than a red blood cell 
• Dispersed in to distal coronary circulation 
• Cleared by Reticulo-endothelial system in liver, spleen and lungs 
• Amount of debris depends on amount of plaque ablated 
• Large amount of debris - Difficult to clear, Slow Flow or No Flow 
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Tips and Tricks 
• Technically Challenging 
• Unfriendly guidewire 
• Use 2.0 over the wire balloon and favorite wire 
• Exchange for Rotawire 
• Extra support vs. floppy - no big difference 
• Limited clearance between burr channel and wire - 0.001” 
• Orthogonal Displacement of Friction 
• Use Dynaglide to advance burr 
• Add RotaGlide to saline flush 
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‘No-reflow’ 
• A feared and common complication 
• Microcirculatory debris 
• Platelet activation (excessive speeds) 
• Coronary vasospasm 
• Important to have pre-treat with anti-platelets 
• Avoid excessive roto speeds 
• Intracoronary verapamil/nitroprusside/adenosine/GTN via 
microcatheter, or OTW wire (inflated) or dual lumen 
catheters/aspiration catheters 
• IABP 
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Tips and Tricks 
• Heart Block 
• Avoid high RPM > 150,000 
• Use good technique 
• Temporary pacemaker 
• Aminophylline pretreatment - 250 mg IV over 20 min 
• For long lesions, when advancer is in the forward position, can advance 
the burr through hemostatic valve while simultaneously moving the 
advancer back to regain more travel 
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Tips and Tricks 
• ‘Sandpaper’ vs. ‘Woodpecker’ techniques 
• ‘Sandpaper’: 3 seconds gentle pressure then 2 seconds 
withdraw to allow perfusion/flush 
• RPMs: 150,000/min vs >160-180,000/min 
• Allow rest, check contrast injections 
• Check ECG, patient symptoms, BP 
• ‘Polish’ 
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Tips and Tricks 
• OK to use Roto then cutting balloon, probably not the other 
way round unless very experienced 
– Some historical basis 
– Small burrs then cutting balloon OK (cost and stress) 
• OK to roto around bends but start with easy cases first 
• OK to go >30 second 
• Be familiar with the wire: I use roto-extra support almost all 
the time 
• Sizing 
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Some Tips 
• If you think about it, you probably should do it 
• If you don’t use it enough, you won’t know how to do it when 
you need to use it 
• If you haven’t seen a complication, your next one could just 
be it 
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Complications 
• Perforation 
• Oversize burrs 
• Guide wire bias 
• Tortuosity 
• Dissection 
• Tamponade from pacing wire 
• Stuck burr 
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Complications 
• Perforation 
• Leave wire in place 
• Exchange for regular wire 
• Reverse anticoagulation 
• Long balloon inflation 
• Covered stent 
• Coil 
• Check echo for pericardial effusion 
• Dissection 
• Tamponade from pacing wire 
• Stuck burr 
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Basic Case 
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Cutting balloon 
• Bulky 
• Hard to deliver 
• Aid in plaque modification so that stents can be well expanded 
• Inflate slowly 
• Deflate slowly 
• Cannot have second wire: wire fracture 
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– Nylon material 
– Predictable & consistent dilatation 
– Secure fixation of flexible atherotomes 
FlextomeTM Cutting BalloonTM Device Components 
Non-compliant Balloon 
• Diameter: 2 - 4mm in 0.25mm increments 
• Length: 6, 10, 15mm 
• Pressure: nominal 6 atm/608kPa; RBP 12 
atm/1216kPa 
Cutting BalloonTM Device 
Mechanism of Action - Summary 
1 Bonan, J Invasiv Cardiol, 1999; 11: 230 
2 Hara et al., Am J Cardiol 2002; 89:1253-1256 
4 Ergene et al, J Invas Cardiol 1998; 10: 70-75 
5 Global Randomized Trial - Cutting Balloon Device Directions for Use; Data on File 
6 Inoue et al., Circulation, 1998; 97:2511-2518 (US SCI #2392) 
7 Yamaguchi et al., J Interven Cardiol 1998; 11(Suppl) S114-S119 
8 Suzuki et al., Amer J Cardiol 1999; 84 Suppl:58P (US SCI #2525) 
9 Taniuchi, et al. The WINNER Registry Catheter Cardiovasc Interv 2004;62:C–36. 
Feature Mechanism of Action 
3-4 atherotomes 
(microsurgical blades) mounted 
longitudinally along a non-
compliant balloon 
Scores the plaque1,2,5,6,7 
Severs the elastic and 
fibrotic continuity of the 
vessel wall1 
May help to prevent balloon 
slippage9 
Non-Compliant Nylon 
Balloon material 
Dilates the target lesion at 
lower pressures2,4,5 
Lumen gain achieved 
primarily through plaque 
compression and less to 
vessel wall expansion2,7,8 
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Inflation & Deflation Technique* 
• Slow inflation—dial up 1 atm(101.3kPa)/5-sec 
• Slow deflation—dial down 1 atm(101.3kPa)/5-sec then pull negative for optimal 
balloon rewrap 
• Repeat angiography 
• Multiple inflations can be performed 
NOTE: Do not torque the catheter between inflations 
Important: Choose shorter lengths for easier access 
Angiosculpt 
• Similar function to cutting balloon 
• But easier to deliver 
• May have additional wire (eg. bifurcations or buddy) 
• May have role in bifurcations (?) 
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©AngioScore 2007. Do Not Copy or Distribute. For Educational Use Only. ML-1040-0001. 
Rev. A 4/07 
2 
• A laser-cut, helical, nitinol scoring element 
• Mounted on a low-profile, semi-compliant 
balloon 
The AngioSculpt Scoring Balloon 
AngioSculpt Mechanism of Action 
Scoring Element strut height 0.005” 
Edges “lock” in 
©AngioScore 2007. Do Not Copy or Distribute. For Educational Use Only. ML-1040-0001. 
Rev. A 4/07 
2 
Costa JR, Mintz GS, Carlier SG et al. Nonrandomized Comparison of Coronary 
Stenting Under IVUS Guidance of Direct Stenting Without Predilation Versus 
Conventional Predilation With a Semi-Compliant Balloon Versus Predilation With 
a New Scoring Balloon. Am J Cardiol, 2007; 100:812-817. 
• Non-randomized, observational study using IVUS to 
compare DES expansion after 3 pre-dilatation 
strategies 
I. Direct stenting without pre-dilatation (n=145) 
II. Pre-dilatation with a conventional semi-compliant balloon (n=117) 
III. Pre-dilatation with the AngioSculpt Scoring Balloon Catheter (n=37) 
• N=299 de novo lesions, all treated with a DES ≥ 2.5 
mm 
• Baseline patient and lesion characteristics well 
matched 
IVUS Pre-Dilatation Study (Costa) 
©AngioScore 2007. Do Not Copy or Distribute. For Educational Use Only. ML-1040-0001. 
Rev. A 4/07 
2 
0.0
0.3
0.6
0.9
1.2
1.5
Direct Stent POBA AngioSculpt
p =0.004 
1.2 + 0.4 
0.8 + 0.4 
0.9 + 0.6 
• p = 0.004 applies to the comparison between Direct Stent vs. 
AngioSculpt 
• comparison between Direct Stent vs. Pre-dil with POBA shows no 
statistical difference 
33% gain 
50% gain 
A
cu
te
 G
ai
n
 (
m
m
) 
Acute Gain (mm) 
Costa JR, Mintz GS, Carlier SG et al. Nonrandomized Comparison of Coronary Stenting Under 
IVUS Guidance of Direct Stenting Without Predilation Versus Conventional Predilation With a Semi-
Compliant Balloon Versus Predilation With a New Scoring Balloon. Am J Cardiol, 2007; 100:812-
817. 
©AngioScore 2007. Do Not Copy or Distribute. For Educational Use Only. ML-1040-0001. 
Rev. A 4/07 
2 
88 
76 76 
-5
3
10
18
25
33
40
48
55
63
70
78
85
93
100
Pre-dil with AngioSculpt Direct Stenting Pre-dil with POBA
p<0.001 
* according to stent 
manufacturer’s 
compliance charts 
% of Predicted Stent Diameter* Reached 
Costa JR, Mintz GS, Carlier SG et al. Nonrandomized Comparison of Coronary Stenting Under 
IVUS Guidance of Direct Stenting Without Predilation Versus Conventional Predilation With a Semi-
Compliant Balloon Versus Predilation With a New Scoring Balloon. Am J Cardiol, 2007; 100:812-
817. 
©AngioScore 2007. Do Not Copy or Distribute. For Educational Use Only. ML-1040-0001. 
Rev. A 4/07 
2 
0%
23%
45%
68%
90%
113%
Direct Stent POBA AngioSculpt
p <0.001 
74% 74% 
89% 
• p < 0.001 applies to the comparison between Direct Stent vs. 
AngioSculpt 
• comparison between Direct Stent vs. Pre-dil with POBA shows no 
statistical difference 
%
 o
f 
St
en
ts
 w
it
h
 F
in
al
 L
u
m
in
al
 A
re
a 
≥ 
5
.0
 m
m
² 
Post-procedure Luminal Area > 5.0mm2 
Costa JR, Mintz GS, Carlier SG et al. Nonrandomized Comparison of Coronary Stenting Under 
IVUS Guidance of Direct Stenting Without Predilation Versus Conventional Predilation With a Semi-
Compliant Balloon Versus Predilation With a New Scoring Balloon. Am J Cardiol, 2007; 100:812-
817. 
Lacrosse NSE 
• Similar to Angiosculpt 
• Has 3 Non-Slip Elements 
• Prevent slippage but also has cutting properties 
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So when? 
• Think about lesion, patient and clinical status 
• Useful in ISR 
• Best to treat calcified lesions upfront 
• Especially if there is a waist after PTCA 
• I personally prefer the rotablator as first line 
• Often use it with Cutting 
balloon/Angiosculpt/Lacrosse NSE 
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